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Post-Polio Health (ISSN 1066-5331)

Vol. 9, No. 1, Winter 1993
Becoming an Intelligent Consumer of Physical Therapy Services, continued

Interview Prior to Physical Assessment

What is the survivor's complete medical history?
What is the survivor's vocational social history?
What is the survivor's perception of function in each major body part?
Has any decline of function occurred in recent years? Are there symptomatic areas of pain?
Are there body parts at circulatory risk, i.e., is there cold intolerance, presence of swelling, discoloration of skin, etc.?
Are there any problems with sleeping?
Are there any problems with breathing or swallowing?
What activities are common for the survivor on a regular basis?
How is endurance for activities?
How accessible is the survivor's home?
How are the survivor's abilities to move in bed, get up and down from a chair, or to walk?
Does the survivor use any special equipment? (i.e., braces, crutches, canes, wheelchairs, feeding devices, breathing devices, etc.) Have these devices changed in recent years? Are there any problems using the current equipment?

Cardiopulmonary

EVALUATION. The components of a basic cardiopulmonary evaluation should be under consideration throughout the physical assessment. The survivor's resting blood pressure, heart rate and respiratory rate should be evaluated. Some description should be made of the survivor's ability to adequately oxygenate each lung lobe and of the survivor's ability to cough and breathe deeply. In conjunction with coughing and deep breathing, a description of the use of abdominal muscles and chest muscles for forces should be included. The PT should also describe any abnormal use of the neck or chest muscles for breathing purposes.

During the rest of the physical evaluation, repeat measurements of the resting heart rate, blood pressures and respiratory rate, and quality should be periodically recorded to let the therapist, survivor and attending physician know how the survivor responds to mild activity such as is conducted during a physical assessment.

Some PTs have the kind of equipment to give the survivor a modified aerobic exercise test using a treadmill or a stationary arm or leg cycle. (Of course, if the survivor has a history of heart or lung disease, it is not wise to do a test of this kind without proper cardiopulmonary monitoring in an office with access to a physician.) An 8-to-12-minute test of areas type may be performed to determine how the survivor responds to this kind of more vigorous, sustained activity, as compared to the intermittent, lower-level activity performed in the rest of the evaluation.

A word of caution here is that performing a sustained aerobic activity before knowing the survivor's true strength as noted below under "STRENGTH TESTING" could be hazardous. Survivors can overexert themselves in the cardiopulmonary testing and suffer pain, muscle tremors, or temporarily increased muscle weakness as a result afterwards.

TREATMENT. If cardiopulmonary abnormalities are found in the evaluation, vital signs should be monitored during any treatment involving exercise. Almost all polio survivors will show a generalized de-conditioned cardiopulmonary response to exercise. They can benefit from instruction in work simplification techniques, energy conservation techniques, body mechanics, etc., to reduce their daily cardiopulmonary demands.

All polio survivors, even in the absence of true lung function impairment, can benefit from instruction in abdominal-diaphragmatic and segmental breathing.

Many survivors have trunk abdominal weakness that results in binding down of the soft tissues of the body, making it difficult to move the chest wall well during breathing. Proper breathing techniques can help address these problems. Survivors who have postural problems that impair oxygen flow will also be helped by using these techniques. Finally, normalizing respirations is known, to reflexively activate the part of the nervous system that promotes bodily relaxation.

Of course, for survivors who do have true respiratory impairment, learning all the above can be potentially lifesaving or life-prolonging. These survivors should also learn assisted coughing techniques.

Flexibility Testing

EVALUATION. Flexibility testing refers to how far into a given movement a person can move a body part. In medical jargon, this is referred to as range of motion (ROM). ROM tests should be performed of all joints in all places. These measurements should be taken accurately with an instrument called a goniometer, which is a standard piece of equipment in all physical therapy departments. (A goniometer is a device similar to a protractor with arms on it that can measure precisely in degrees, the amount of movement present at any joint in any plane.) Simply "eyeballing" the available movement at the joints is not acceptable.

There are many texts that cite "normal" values for ROM at each joint in all planes. These various sources disagree on what "normal" is. PTs should define whatever values they have chosen to use as representative of "normal" in light of whether or not the chosen values are at the upper end or at the lower end of those noted in the available resources.

In interpreting ROM values, the PT should show survivors a ratio of their values over the value that the therapist is considering normal. For example, if the normal ROM that the PT is considering for straight leg raising is 80 degrees and the survivor's ROM is 60 degrees, the ROM should be expressed at 60/80. This is helpful so that both the survivor and the therapist are aware that the survivor has a 25% deficit in flexibility.

TREATMENT. The importance of adequate flexibility in all patients, but especially in polio survivors, cannot be overstressed. It is well-documented by people active in the acute phase of polio treatment during the epidemics earlier in this century (Sister Kenny and current lecturer Dr. Thomas P Anderson, for example), that muscles affected by polio easily become "stiff," and must undergo continual stretching to maintain adequate flexibility. Without adequate flexibility, it becomes very difficult for a person to use whatever strength is available in that body part. Poor flexibility can also cause pain and deformity. Too much flexibility on the other hand can cause what Florence Kendall refers to as "stretch weakness." This, too, makes it difficult to use the available strength.

In general, I have always used the "normal" values as a firm target to shoot for in most people to assure as normal a biomechanic force at a joint as possible. Surgeries, arthritis, or bony deformities may impair a person's ability to achieve "normal" ROM. However a good passive stretching program performed by a friend or family member goes a long way toward minimizing pain and normalizing movement patterns. Self-stretching is usually difficult to perform due to pain, weakness, and substitution patterns.

In certain cases amongst polio survivors, some degree of "tightness" in certain muscles may assist function. For example, in a patient with weak forearm and finger muscles, a certain degree of tightness selectively permitted in these muscle groups can allow the patient to have the appearance of more "strength" than he/she would otherwise have. Another example might be if a patient has weak knee extensor muscles and weak buttock muscles, a certain amount of tightness in the inner aspect of the thigh may make it easier for the patient to use the available strength in the thigh. However, these examples are quite variable and extremely dependent on all the symptoms that present in a given patient. Only a well-trained therapist can discern, in conjunction with the patient's physician, if certain areas of selected tightness might be adaptive for a particular person.

Read the conclusion of this article by Marianne T. Weiss, PT, published in Vol. 9, No. 2.

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